Understanding trends and variation in paediatric fracture management in England

Sarah Lucas

11 November 2024

Foreword

In this report we have taken paediatric Emergency department (ED) attendances (0-16yrs old) across England (2019-23) and looked at a select number of paediatric fractures where either national guidance or published/emerging evidence suggests limited intervention, imaging or follow up is required. These include clavicle (collarbone), forearm and toe fractures. Given our results we believe future UK wide analysis of other fracture types and/or a wider age range (Adults) may prove beneficial.

For paediatric fractures regarded as minor or ‘low need’, our analysis demonstrates:

  • If the number of follow up appointments was reduced to the lowest quartile of English Trusts circa. 30,000 appointments could be saved annually. (Slide 40 & 49)

  • Many clavicle fractures, commonly accepted to heal without intervention, have two or more follow up appointments when evidence suggests none are required. (Slide 23 & 41)

  • Marked variance exists across Trusts in the proportion of fractures with follow up and how that occurs (virtual vs face to face). (Slide 39-40)

Our analysis demonstrates between 2019-23 the proportion of forearm fractures manipulated:

  • Has reduced in theatre by 50% (Slide 27) and increased in ED (Slide 26).

  • Total manipulations (theatre or ED) have reduced by 22% (Slide 28).

Our data shows that forearm fractures are the most common fracture in children and in 2022-23 alone over 25,000 had no follow up (Slide 23). Along with the forearm manipulation data this collectively suggests a fundamental change in forearm fracture management has occurred across England, likely driven by Get It Right First Time (GIRFT) targets and recent/ongoing research (FORCE & CRAFFT).

Lastly, our analysis suggests marked regional variation in fracture incidence exists (Slide 13) and is unaccounted in the current GIRFT/Model hospital ‘Wrist manipulations in theatre’ dataset. We have formulated an alternative and potentially more nuanced version accounting for regional variation. Interestingly, Trusts currently considered either in the top or bottom quartiles markedly change position within our proposed model (Slide 43-44).

In conclusion we believe our analysis can help set future GIRFT targets driving change and savings across the NHS.

Dr Patrick Aldridge, Consultant Paediatrician, Paediatric Emergency Department Clinical Lead at NHS Frimley Health Foundation Trust

Report summary


This report sets out to understanding the opportunities to reduce hospital activity through wider adoption of more conservative management of selected paediatric fractures.

The work was funded by NHS England as part of the New Hospitals Programme.

This work may provide an opportunity to create a new activity mitigator in the NHP model to allow trusts to estimate the impact of adopting conservative management of certain paediatric fractures on their future activity levels.

Key findings:

  • Over the last 5 years there has been a trend towards more conservative management of paediatric fractures, but further activity savings that could be made.

  • While nationally manipulations in theatre have decreased in recent years, at some trusts there is still scope to reduce the proportion of forearm and elbow fractures manipulated in theatre. This could further half the number of elbow and forearm manipulations performed in England.

  • There is scope to reduce the number of x-rays for clavicle and toe fractures in emergency care in England by almost a fifth.

  • There is scope to reduce the number of follow-up appointments for elbow, forearm, clavicle, tibia/fibula and toes fractures in England by a third.

Background

Epidemiology of paediatric fractures

One hospital in Ireland calculated a paediatric fracture incidence rate of approximately 29 fractures/1,000/year1. The most common fracture was distal radial/buckle fractures (27.2%), followed by distal humerus /supracondylar fracture (13.9%), ankle fractures (9.2%), phalanx fractures (8.3%), and radial/ulnar metaphysis fractures (5.7%). It is suggested the incidence rate will depend on the social emphasis on encouraging physical activity1.

Between 2012–2019, 368,120 children under 18 were admitted to English NHS hospitals with a fracture; 256,008 (69.5%) were upper limb and 85,737 (23.3%) were lower limb fractures2. The annual incidence of upper limb fractures was highest in children aged 5–9 (348.3 per 100, 000 children).

The total fracture incidence rate in the UK was found by one study to be 1,370 fractures per 100,000 children3, while another found the incidence of distal radius fractures to be 337 fractures per 100,000 children at one UK trauma centre4.

Paediatric fracture management

British Society for Children’s Orthopaedic Surgery (BSCOS) guidance suggests that no referral/follow up is required for many fractures of the clavicle, elbow, wrist and toes where there is no or minimal displacement5.

The FORCE study found in children with a torus fracture of the distal radius there was no difference in outcomes between those who were offered of a bandage and immediate discharge (as per UK National Institute for Health and Clinical Excellence recommendations) and those receiving current treatment of rigid immobilisation and follow-up6.

One study in Scotland found that uncomplicated paediatric clavicle fractures can be managed without x-rays in the ED as the use of x-rays did not influence fracture management or add valuable information to clinicians’ assessment7.

  1. Baig MN. (2017) A Review of Epidemiological Distribution of Different Types of Fractures in Paediatric Age. Cureus. 28;9(8):e1624
  2. Marson BA et al. (2021) Trends in hospital admissions for childhood fractures in England. BMJ Paediatr Open. 10;5(1):e001187
  3. Moon RJ et al (2016) Ethnic and geographic variations in the epidemiology of childhood fractures in the United Kingdom. Bone. 85:9-14
  4. Mamoowala N et al (2019) Trends in paediatric distal radius fractures: an eight-year review from a large UK trauma unit. Ann R Coll Surg Engl. 101(4):297-303
  5. Modifiable Templates for Management of Common Fractures. https://www.bscos.org.uk/public/resources
  6. Perry DC et al. (2022). Immobilisation of torus fractures of the wrist in children (FORCE): a randomised controlled equivalence trial in the UK. Lancet; 400(10345):39-47
  7. Lirette MP et al. (2018) Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study. BMJ Paediatr Open. 10;2(1):e000304

Background (continued)


Manipulation of paediatric fractures

A GIRFT report on Paediatric Trauma and Orthopaedic Surgery found that over 250 weeks of theatre time a year had been used for manipulation of forearm fractures between 2016 and 20191. A significant proportion of these displaced or angulated wrist fractures could have been manipulated and cast in the emergency department rather than being admitted and treated in the operating theatre. The GIRFT report found significant variation between trusts in the number of manipulations being performed in theatre. If the number of fractures manipulated in theatre at all trusts was reduced to the level seen in trusts with well-developed emergency department manipulation protocols there would be an 80% reduction in manipulations in theatre, reducing theatre time for forearm/wrist fractures to under 57 weeks.

Due to pressures on hospitals from the COVID-19 pandemic the British Orthopaedic Association developed guidelines for the early management of distal forearm fractures in children. A study conducted at one trust found that the implementation of these guidelines resulted in 86% of distal forearm fractures in children being manipulated in the emergency department, an increase from 32% prior to the COVID pandemic2. This saved approximately 63 hours of theatre time in the six-month study period.

The GIRFT report did highlight reluctance to perform procedures in the emergency department because of worries about breaching the 4 hour emergency department treatment target, a lack of space/facilities to perform sedation and a lack of familiarity with techniques1.





  1. Paediatric Trauma and Orthopaedic Surgery. GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/girft-reports/
  2. Fink BE etal (2023) Early Management of Paediatric Wrist and Forearm Fractures in a Busy District General Hospital Emergency Department: A Retrospective Cohort Comparison Study and Audit of BOAST Guidelines. Cureus. 15(7):e41325.

Aims


  1. Add to the information in the literature on the incidence rate of various paediatric fractures (forearm, elbow, clavicle, tibia/fibula and toe) recorded in emergency care in England.

  2. Understand the trends in management of these fracture types over time, e.g. have changes in guidance during COVID-19 changed the trends in management of fractures in emergency care.

  3. Investigate the variation in management of these fracture types between trusts, and the potential activity savings if there was more widespread conservative management, such as reducing unnecessary follow-ups appointments and manipulation in the emergency department rather than in theatre.

Data sources and Study population

The study population included all those aged 16 and under who attended an emergency care centre in England between April 2019 and March 2024 and had a SNOMED code for a closed fracture of toe, clavicle, elbow, forearm or tibia/fibula recorded (see Appendices A-C for full code lists).

Records at a patient level were taken from the Emergency Care dataset (ECDS) and linked with any subsequent fracture related activity recorded in the Outpatient (OPA) and Admitted Patient Care Episode (APCE) datasets in the 3 months post-emergency care attendance. All data were accessed through the National Commissioning Data Repository (NCDR).

This study focuses on closed fractures as this is where there is scope for more conservative management; open, pathological, osteoporotic and birth trauma fractures have been excluded, alongside fractures of the great toe, which should all be followed up.

Incidence rates were calculated using the Office of National Statistics (ONS) mid-year population estimates by age and sex1.

The coding of fractures is not sufficiently detailed and reliable to determine specific fracture types, and thus what would be the appropriate treatment at an individual patient level. For example, we cannot identify buckle fractures, which we know could be treated more conservatively. However, we could calculate the proportion of children with each fracture type that:

  • had a fracture manipulated in theatre (only includes closed manipulations; those requiring internal fixation and re-manipulations are excluded)
  • had a fracture manipulated in the emergency department
  • received a follow-up outpatient appointment
  • had a referral/appointment for physiotherapy
  • had an X-ray in the emergency department

Full details of the coding used to identify these procedures/attendances is included in Appendix D.

  1. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/populationestimatesforukenglandandwalesscotlandandnorthernireland

Incidence rates


Incidence rates were calculated to get a better understanding of the the scale of paediatric fracture attendances in emergency care, including

  • trends over time

  • the most common fracture types, and how these vary by age and sex

  • Variation by region to determine whether there may be a greater burden of fractures in some ICB areas

These incidence rates are not the incidence of fractures, but should be considered as the incidence of a recorded emergency care attendance for the specified closed fracture types.

The crude annual incidence rates per 100,000 children were calculated using ONS mid-year population estimates, broken down by age and sex.

Characteristics of the cohort

 

Clavicle
(N=73,303)

Elbow
(N=103,958)

Forearm
(N=347,472)

Tibia/Fibula
(N=65,368)

Toe
(N=69,797)

Overall
(N=659,898)

Sex

  Female

22,462 (30.6%)

47,294 (45.5%)

135,026 (38.9%)

26,375 (40.3%)

28,358 (40.6%)

259,515 (39.3%)

  Male

50,650 (69.1%)

56,397 (54.2%)

211,579 (60.9%)

38,820 (59.4%)

41,312 (59.2%)

398,758 (60.4%)

  Missing/Unknown

191 (0.3%)

267 (0.3%)

867 (0.2%)

173 (0.3%)

127 (0.2%)

1,625 (0.2%)

Age

  0-4 yrs

19,718 (26.9%)

25,978 (25.0%)

43,446 (12.5%)

29,284 (44.8%)

3,385 (4.8%)

121,811 (18.5%)

  5-10 yrs

22,129 (30.2%)

50,687 (48.8%)

161,671 (46.5%)

14,097 (21.6%)

25,130 (36.0%)

273,714 (41.5%)

  11-16 yrs

31,456 (42.9%)

27,293 (26.3%)

142,355 (41.0%)

21,987 (33.6%)

41,282 (59.1%)

264,373 (40.1%)

Ethnicity

  Asian or Asian British

3,844 (5.2%)

9,155 (8.8%)

21,846 (6.3%)

4,368 (6.7%)

4,342 (6.2%)

43,555 (6.6%)

  Black or Black British

1,721 (2.3%)

2,163 (2.1%)

7,200 (2.1%)

2,113 (3.2%)

1,745 (2.5%)

14,942 (2.3%)

  Mixed

2,291 (3.1%)

3,663 (3.5%)

10,748 (3.1%)

2,477 (3.8%)

2,226 (3.2%)

21,405 (3.2%)

  Other Ethnic Groups

2,050 (2.8%)

2,970 (2.9%)

9,725 (2.8%)

2,142 (3.3%)

1,781 (2.6%)

18,668 (2.8%)

  White

56,194 (76.7%)

76,296 (73.4%)

264,921 (76.2%)

48,088 (73.6%)

52,964 (75.9%)

498,463 (75.5%)

  Missing/Unknown

7,203 (9.8%)

9,711 (9.3%)

33,032 (9.5%)

6,180 (9.5%)

6,739 (9.7%)

62,865 (9.5%)

IMD Quintiles

  1- Most deprived

16,116 (22.0%)

26,418 (25.4%)

80,955 (23.3%)

16,507 (25.3%)

16,164 (23.2%)

156,160 (23.7%)

  2

13,544 (18.5%)

20,349 (19.6%)

66,825 (19.2%)

12,959 (19.8%)

13,262 (19.0%)

126,939 (19.2%)

  3

13,904 (19.0%)

19,029 (18.3%)

64,685 (18.6%)

11,835 (18.1%)

13,021 (18.7%)

122,474 (18.6%)

  4

14,261 (19.5%)

18,670 (18.0%)

65,157 (18.8%)

11,743 (18.0%)

13,125 (18.8%)

122,956 (18.6%)

  5- Least deprived

14,698 (20.1%)

18,396 (17.7%)

66,501 (19.1%)

11,662 (17.8%)

13,630 (19.5%)

124,887 (18.9%)

  Missing/Outside England

780 (1.1%)

1,096 (1.1%)

3,349 (1.0%)

662 (1.0%)

595 (0.9%)

6,482 (1.0%)

Emergency Dept type

  Major Emergency Dept

57,459 (78.4%)

81,863 (78.7%)

259,815 (74.8%)

54,357 (83.2%)

44,682 (64.0%)

498,176 (75.5%)

  Urgent Treatment Centre/Walk in centre

15,836 (21.6%)

22,088 (21.2%)

87,614 (25.2%)

10,993 (16.8%)

25,113 (36.0%)

161,644 (24.5%)

  Mono-specialty Emergency Dept

0 (0%)

0 (0%)

1 (0.0%)

2 (0.0%)

0 (0%)

3 (0.0%)

  Same Day Emergency Care

8 (0.0%)

7 (0.0%)

42 (0.0%)

16 (0.0%)

2 (0.0%)

75 (0.0%)

Day of ED attendance

  Weekday

50,917 (69.5%)

74,537 (71.7%)

253,259 (72.9%)

46,088 (70.5%)

51,859 (74.3%)

476,660 (72.2%)

  Weekend

22,386 (30.5%)

29,421 (28.3%)

94,213 (27.1%)

19,280 (29.5%)

17,938 (25.7%)

183,238 (27.8%)

Time of ED attendance

   Daytime 7am to 7pm

62,907 (85.8%)

87,237 (83.9%)

301,785 (86.9%)

55,995 (85.7%)

61,135 (87.6%)

569,059 (86.2%)

  Nighttime 7pm to 7am

10,396 (14.2%)

16,721 (16.1%)

45,687 (13.1%)

9,373 (14.3%)

8,662 (12.4%)

90,839 (13.8%)

Year of ED attendance

  2019/20

14,565 (19.9%)

21,103 (20.3%)

66,577 (19.2%)

12,711 (19.4%)

14,953 (21.4%)

129,909 (19.7%)

  2020/21

11,612 (15.8%)

16,942 (16.3%)

56,492 (16.3%)

10,719 (16.4%)

9,969 (14.3%)

105,734 (16.0%)

  2021/22

16,739 (22.8%)

21,943 (21.1%)

82,556 (23.8%)

14,190 (21.7%)

15,034 (21.5%)

150,462 (22.8%)

  2022/23

15,119 (20.6%)

21,840 (21.0%)

71,844 (20.7%)

13,740 (21.0%)

14,604 (20.9%)

137,147 (20.8%)

  2023/24

15,268 (20.8%)

22,130 (21.3%)

70,003 (20.1%)

14,008 (21.4%)

15,237 (21.8%)

136,646 (20.7%)

Incidence rates for England (2023/2024)



Annual crude incidence of attendance in emergency care with a fracture, per 100,000 children

Type

Female
0-4 yrs

Female
5-10 yrs

Female
11-16 yrs

Male
0-4 yrs

Male
5-10 yrs

Male
11-16 yrs

Total

Clavicle

131

77

62

131

154

250

136

Elbow

172

284

95

175

271

174

197

Forearm

270

786

362

273

828

1,024

622

Tibia/Fibula

174

72

71

213

76

171

124

Toe

17

125

160

26

142

281

135

Total

764

1,344

750

818

1,471

1,900

1,214


Forearm fractures are the most common followed by elbow fractures.

The overall fracture rate was lowest during the peak of the COVID-19 pandemic (2020/2021) and highest the following year (2021/2022).

Incidence rate by age/sex group


Denominator for calculating incidence rate is the number of children of that age and sex in England taken from the ONS mid-year population estimates, e.g. incidence per 100,000 0-4 year old males.


Tibia/Fibula fractures are most common in those aged 0-4 years.

Elbow fractures are most common in those aged 5-10 years.

In the 11-16 year old age group all fracture types are more common in males compared to females, with males aged 11-16 years old having the highest incidence of clavicle, forearm and toe fractures.

Most common fracture types (2023/2024)


SNOMED description

Number

Percentage

Closed fracture of radius (disorder)

Forearm

48,043

35.2

Elbow fracture - closed (disorder)

Elbow

18,613

13.6

Closed fracture of radius AND ulna (disorder)

Forearm

17,498

12.8

Closed fracture of clavicle

Clavicle

15,259

11.2

Closed fracture of phalanx of foot (disorder)

Toe

15,232

11.1

Closed fracture of tibia (disorder)

Tibia/Fibula

8,549

6.3

Closed fracture of ulna (disorder)

Forearm

4,347

3.2

Closed supracondylar fracture of humerus (disorder)

Elbow

3,394

2.5

Closed fracture of fibula (disorder)

Tibia/Fibula

3,278

2.4

Closed fracture of tibia AND fibula (disorder)

Tibia/Fibula

2,145

1.6

Closed Monteggia's fracture (disorder)

Elbow

108

0.1

Closed Galeazzi fracture (disorder)

Forearm

65

0.0

Closed fracture of distal end of radius (disorder)

Forearm

23

0.0

Only showing those fracture types recorded 10 or more times


The majority of fractures are recorded within the emergency care dataset under just a few snomed codes.

There are codes available that specify whether a radius fracture is proximal or distal, but these are not used, instead the general code ‘Closed fracture of radius (disorder)’ is used. We have classified this as a forearm fracture but some of these might be proximal radius fractures and therefore more accurately classified at elbow fractures.

Fractures of great toe were excluded as these should be followed up, however <10 codes related to the fracture of the great toe were recorded over the whole 5 year period in England, suggesting that many of great toe fractures may be coded as ‘Closed fracture of phalanx of foot (disorder)’ and thus included within our dataset.

Incidence rates per 100,000 by ICB (2023/2024)

ICB

Clavicle

Elbow

Forearm

Tibia/Fibula

Toe

Total

% of ED attendances
w/o diagnosis

NHS Cornwall and the Isles of Scilly ICB

220

365

1,136

177

262

2,159

1

NHS Herefordshire and Worcestershire ICB

201

308

1,016

142

269

1,934

22

NHS Shropshire, Telford and Wrekin ICB

215

292

971

139

230

1,847

24

NHS Gloucestershire ICB

222

186

1,004

183

205

1,800

37

NHS Derby and Derbyshire ICB

185

256

905

169

232

1,747

13

NHS Somerset ICB

195

280

925

150

190

1,740

18

NHS Dorset ICB

188

280

857

145

194

1,664

26

NHS South Yorkshire ICB

192

305

803

169

193

1,662

18

NHS Norfolk and Waveney ICB

198

281

842

167

165

1,653

8

NHS Devon ICB

188

262

871

163

150

1,634

23

NHS Black Country ICB

164

304

818

148

144

1,578

42

NHS Sussex ICB

162

241

825

128

171

1,528

16

NHS North East and North Cumbria ICB

146

232

748

148

186

1,460

26

NHS Humber and North Yorkshire ICB

187

213

727

136

162

1,425

18

NHS Lincolnshire ICB

146

214

736

134

187

1,417

6

NHS Coventry and Warwickshire ICB

174

189

717

146

149

1,375

16

NHS Bedfordshire, Luton and Milton Keynes ICB

132

246

688

110

146

1,322

22

NHS Greater Manchester ICB

140

196

708

114

164

1,322

32

NHS Mid and South Essex ICB

138

215

660

163

137

1,312

6

NHS Cheshire and Merseyside ICB

150

221

661

139

141

1,311

31

NHS Hampshire and Isle of Wight ICB

134

231

638

139

125

1,267

19

NHS West Yorkshire ICB

156

200

621

132

133

1,243

23

NHS Birmingham and Solihull ICB

127

236

603

123

142

1,232

18

NHS Bristol, North Somerset and South Gloucestershire ICB

125

226

589

177

91

1,208

7

NHS Nottingham and Nottinghamshire ICB

131

216

597

150

114

1,208

13

NHS Northamptonshire ICB

144

202

578

97

118

1,139

13

NHS Bath and North East Somerset, Swindon and Wiltshire ICB

145

191

571

116

94

1,117

24

NHS South West London ICB

130

111

569

149

141

1,101

39

NHS Cambridgeshire and Peterborough ICB

146

179

550

99

120

1,094

45

NHS Suffolk and North East Essex ICB

145

157

523

106

129

1,060

27

NHS Lancashire and South Cumbria ICB

122

170

530

124

107

1,052

31

NHS Hertfordshire and West Essex ICB

110

150

506

100

113

980

22

NHS Surrey Heartlands ICB

130

162

460

102

115

970

31

NHS Leicester, Leicestershire and Rutland ICB

99

168

446

128

94

934

2

NHS Staffordshire and Stoke-on-Trent ICB

87

121

503

88

125

923

12

NHS North Central London ICB

92

135

438

107

92

864

34

NHS Kent and Medway ICB

85

104

440

63

109

801

48

NHS North West London ICB

82

132

393

88

74

770

38

NHS Buckinghamshire, Oxfordshire and Berkshire West ICB

84

116

356

78

55

689

39

NHS Frimley ICB

70

118

327

77

46

639

35

NHS South East London ICB

62

103

293

72

69

598

23

NHS North East London ICB

59

121

276

80

47

584

33

While lower rates in some areas will be the result of some trusts in those areas not reliably recording diagnoses codes for emergency care attendances there is evidence of variation in incidence rates by ICB. For example, diagnoses rates are high in both the Cornwall and Leicestershire ICB areas, but incidence rates are considerably lower in the Leicestershire ICB area compared to Cornwall.

Proportion of ED attendances with a fracture code (2022/2023)

Percentage of all emergency care attendances for those aged 16 or under where a fracture code is recorded.

Percentage of emergency care attendances with a diagnosis code for those aged 16 or under, where the recorded code is for a fracture.

There is considerable variability between providers in the percentage emergency care attendances where a fracture is recorded. Even when accounting for the different rates of recording diagnoses seen between trusts, the percentage of diagnoses that are fractures varies considerably.

These differences could be due to:

  • Alternative provision locally, e.g. in some areas there is independent urgent care provision available.

  • Regional differences in fracture rate, which may be related to levels of physical activity, visitors from out of area and the demographic of the area.

  • Issues with coding/reporting, including variation in what diagnoses are recorded.

Summary of analysis of incidence rates


  • In children, forearm fractures are the most common followed by elbow fractures.

  • Fractures of tibia/fibula are most common in under 5. Elbow fractures are most common in 5-10 year olds. For older children the fracture rate is higher in boys compared to girls, with boys aged 11-16 years having the highest rates of clavicle, forearm and toe fractures.

  • There is significant seasonality with much higher fractures rates seen in the summer months, likely related to increased outdoor physical activity.

  • Incidence rates vary considerably by ICB region and by trust. Some of these differences will be due to issues with coding and reporting of fractures, as the proportion of emergency care attendances without a diagnosis code recorded varies significantly between trusts. However, some of the differences seen between trusts are likely related to availability of alternative provision locally (independent urgent treatment centres or alternative specialist paediatric provision nearby) or due to differences between areas in the patient demographic and in levels of physical activity.

  • Lack of detailed coding of fractures means some fractures may be misclassified, e.g. it is not possible to determine which radius fractures may be more accurately classified as elbow rather than forearm fractures, and great toe fractures are not specifically recorded.

Exploring fracture management


There have been recent studies and guidance suggesting a more conservative approach to managing paediatric fractures should be adopted. Therefore we set out to consider whether paediatric fracture management has changed over the last 5 years.


We have investigated:

  • The proportion of fracture that are x-rayed within the emergency department

  • The proportion of fractures that receive an outpatient follow-up appointment, which could be an outpatient or physiotherapy appointment.

  • The types of follow-up appointments, including looking specifically at physiotherapy appointments.

  • The proportion of fractures being manipulated and the trends in manipulations in both the emergency department and in theatre.

Percentage of fractures with a X-ray recorded in the ED



The majority of fractures of all types are x-rayed in the emergency department, although the percentage of toe fractures x-rayed is slightly lower.

Percentage of fractures with a follow-up appointment



These data give the proportion of children with fractures that receive at least one follow-up appointment, which could be either an outpatient department appointment or physiotherapy appointment.

Follow-up rates are lower for toe and clavicle fractures, and highest for tibia/fibula and elbow fractures.

In the past 5 years, there has been over a 10% reduction in the proportion of emergency department attendances for clavicle and forearm where a follow-up appointment is given.

Proportion of face-to-face vs virtual follow-up appointments



During the COVID-19 pandemic the proportion of follow up appointments conducted face-to-face significantly decreased, and this reduction in face-to-face follow-ups has been maintained.

Only showing data for the first outpatient attendance

Follow-up outpatient appts with and without procedures



Over the last 5 years the proportion of children with a fracture that had a follow-up outpatient appointment where a procedure was recorded has decreased, especially following COVID-19.

The proportion of follow-up outpatient appointments with no procedures recorded has remained relatively stable over time. Although for tibia/fibula and elbow fractures there was a slight increase in the proportion of these follow-ups at the start of the pandemic which has remained in the post-pandemic.

Only showing data for the first outpatient attendance

Outpatient procedures recorded following ED attendance


Only showing data for the first outpatient attendance and the most common types of procedures

The majority of procedures are related to casts/bandages/splints, and the numbers of these have decreased post-pandemic, as has the number of diagnostic imaging procedures during follow-up appointments. This likely indicates a move towards more conservative management of fractures, and to be expected with an increased proportion of follow-ups being conducted virtually.

There are also some procedures of joint (OPCS code W92) recorded in these outpatient follow-up appointments (this code includes procedures such as: distension of joint, examination of joint including under image intensifier or anaesthetic, chemical or radiation synovectomy)

The number of manipulations recorded during outpatient appointments is extremely small.

It is fairly common for more than one procedure to be recorded.

Number of follow-up appointments (2022/23)


Includes all outpatient attendances, including physiotherapy appointments, in the 3 months post-fracture.




Mean

Median

Clavicle

1.1

1

Elbow

2.0

2

Forearm

1.5

1

Tibia/Fibula

2.4

2

Toe

0.6

0

Percentage of fractures referred for physiotherapy



The percentage of fractures with a referral/outpatient attendance for physiotherapy in the 3-months post-fractures are higher for those with elbow and tibia/fibula fractures, but generally very low for the other fracture types.

Generally the proportion referred to physiotherapy has remained relatively stable, but there is a trend towards an increase the proportion of tibia/fibula fractures referred.

Factors influencing whether a follow-up appointment is given

Odds Ratio

Confidence Intervals

P value

(Intercept)

2.20

2.15 to 2.25

<0.001*

Sex

Female

1.00

Reference

Male

1.12

1.11 to 1.13

<0.001*

Age

5-10 yrs

1.00

Reference

0-4 yrs

0.96

0.94 to 0.97

<0.001*

11-16 yrs

1.15

1.13 to 1.16

<0.001*

Ethnicity

White

1.00

Reference

Asian or Asian British

1.05

1.03 to 1.08

<0.001*

Black or Black British

1.14

1.1 to 1.19

<0.001*

Mixed

1.01

0.98 to 1.05

0.34

Other Ethnic Groups

1.00

0.97 to 1.04

0.86

Missing/Unknown

0.97

0.95 to 0.98

<0.001*

IMD Quintiles

1- Most deprived

1.00

Reference

2

1.08

1.07 to 1.1

<0.001*

3

1.03

1.01 to 1.04

<0.001*

4

1.05

1.04 to 1.07

<0.001*

5- Least deprived

1.08

1.06 to 1.1

<0.001*

Department type

Major Emergency Department

1.00

Reference

Urgent Treatment Centre/Walk in centre

0.96

0.95 to 0.98

<0.001*

Day of the week

Week

1.00

Reference

Weekend

1.06

1.05 to 1.08

<0.001*

Time of day

Day 7am-7pm

1.00

Reference

Night 7pm to 7am

1.12

1.1 to 1.13

<0.001*

Time of year

Autumn

1.00

Reference

Winter

0.94

0.93 to 0.96

<0.001*

Spring

0.95

0.94 to 0.97

<0.001*

Summer

0.99

0.97 to 1

0.06

Year

2019/20

1.00

Reference

2020/21

0.85

0.83 to 0.86

<0.001*

2021/22

0.79

0.77 to 0.8

<0.001*

2022/23

0.72

0.71 to 0.73

<0.001*

2023/24

0.72

0.71 to 0.73

<0.001*

Fracture type

Clavicle

0.79

0.78 to 0.8

<0.001*

Forearm

1.00

Reference

Elbow

2.47

2.43 to 2.52

<0.001*

Tibia/Fibula

2.09

2.05 to 2.14

<0.001*

Toe

0.37

0.36 to 0.37

<0.001*

Logistic regression was used to determine which variables are independently associated with a follow-up appointment being given. This allows us to identify which characteristics and thus which groups of children are more or less likely to be given a follow-up appointment. An odds ratio of greater than 1 indicates an increased chance of having a follow-up appointment compared to the reference group, while an odds ratio below 1 indicates a reduced chance of a follow-up.

Children are more likely to be given a follow-up appointment (outpatient/physiotherapy) if they are

  • male

  • 11-16 years old

  • from an asian or black background

  • living in a less deprived area

They are also more likely to have a follow-up appointment if they attended

  • an emergency department

  • on a weekend

  • at nighttime

Those attending in more recent years were less likely to have a follow-up appointment, even after attempting to adjust for case-mix, further indicating there has been a move towards fewer follow-up appointments.

Percentage of fractures manipulated in the ED



The percentage of forearm fractures manipulated in the emergency department has increased over the last 5 years, with a large increase seen during the COVID-19 pandemic. There is also a noticeable seasonal trend with a greater percentage of fractures manipulated in the emergency department during the summer months.

The percentage of tibia/fibula fractures manipulated in the emergency department has also increased, but there is little change in the other fracture types over time.

Percentage of fractures manipulated in theatre



The percentage of forearm fractures manipulated in theatre has decreased significantly over the last 5 years (by over 50%), with a greater percentage of fractures manipulated in theatre during the summer months.

The percentage of tibia/fibula fractures manipulated in theatre as also decreased.

Proportion of fractures manipulated


The total number of forearm fractures being manipulated either in the emergency department or theatre has decreased by 22% in the last 5 years.

Proportion of fractures manipulated in ED vs theatre


Over the last 5 years the proportion of manipulations that are performed in theatre has decreased mostly notably for forearm fractures where now over half of all manipulations are performed in the emergency department.

Use of emergency depts vs urgent treatment/walk-in centres



The number of fractures seen in emergency departments is relatively stable over time, however there is an increase in fractures being seen in urgent treatment/walk-in centres, although this may be an artefact of improved recording of fracture attendances in urgent treatment/ walk-in centres.

Manipulations, following ED or UTC attendance (2022/23)

A greater proportion of those attending emergency departments, compared to urgent treatment centres, have their fractures manipulated in the emergency department, which is to be expected given that manipulations would generally not be done within an urgent treatment centres.

However, the percentage of fractures manipulated in theatre is also higher for those attending emergency departments, suggesting those with more obvious/complex fractures that require manipulation are more likely to attend emergency departments, or be sent there from urgent treatment centres (in a small number of cases where a child attended 2 emergency care sites on the same day, we have only included the second attendance).



In 2022/23, 73% of fractures were seen in the emergency department, and 27% in urgent treatment centres.

However, 90% of fractures requiring manipulations were seen in the emergency department and around 10% in urgent treatment centres, further indicating that those with fractures that require manipulation are more likely to attend an emergency department rather than an urgent treatment centre.

:::

Follow-up appts following ED or UTC attendance (2022/23)


The percentage of fractures where a follow-up appointment is given is broadly similar at urgent treatment centres and emergency departments.

Factors influencing manipulation of forearm fractures in theatre

Odds Ratio

Confidence Intervals

P value

(Intercept)

5.87

5.29 to 6.52

<0.001*

Sex

Female

1.00

Reference

Male

0.93

0.88 to 0.99

0.01*

Age

5-10 yrs

1.00

Reference

0-4 yrs

1.62

1.48 to 1.77

<0.001*

11-16 yrs

0.51

0.48 to 0.54

<0.001*

Ethnicity

White

1.00

Reference

Asian or Asian British

0.81

0.73 to 0.91

<0.001*

Black or Black British

0.49

0.41 to 0.59

<0.001*

Mixed

0.69

0.6 to 0.8

<0.001*

Other Ethnic Groups

0.54

0.46 to 0.62

<0.001*

Missing/Unknown

0.85

0.78 to 0.93

<0.001*

IMD Quintiles

1- Most deprived

1.00

Reference

2

0.76

0.7 to 0.82

<0.001*

3

0.71

0.66 to 0.77

<0.001*

4

0.68

0.63 to 0.74

<0.001*

5- Least deprived

0.62

0.57 to 0.67

<0.001*

Department type

Major Emergency Department

1.00

Reference

Urgent Treatment Centre/Walk in centre

5.12

4.58 to 5.74

<0.001*

Day of the week

Week

1.00

Reference

Weekend

1.09

1.03 to 1.15

<0.001*

Time of day

Day 7am-7pm

1.00

Reference

Night 7pm to 7am

1.12

1.04 to 1.2

<0.001*

Time of year

Autumn

1.00

Reference

Winter

0.87

0.8 to 0.95

<0.001*

Spring

1.06

0.99 to 1.14

0.09

Summer

1.17

1.09 to 1.25

<0.001*

Year

2019/20

1.00

Reference

2020/21

0.43

0.4 to 0.47

<0.001*

2021/22

0.41

0.38 to 0.45

<0.001*

2022/23

0.28

0.26 to 0.3

<0.001*

2023/24

0.20

0.18 to 0.22

<0.001*

Logistic regression was used to allow us to identify which characteristics and thus which groups of children are more or less likely to have their forearm fracture manipulated in theatre.

Includes only forearm fractures that are manipulated, either the emergency department or in theatre (excludes those where manipulation is recorded in both ED and theatre) to determine what factors might be influencing the decision to manipulate a fracture in theatre rather than in the emergency department.

Children are more likely to have a fracture manipulated in theatre if they are

  • female

  • under the age of 5

  • white

  • living in a more deprived area

They are also more likely to have a manipulation in theatre if they attended

  • an urgent treatment centre

  • on a weekend

  • at nighttime

  • in the summer

Those attending in more recent years were less likely to have their fracture manipulated in theatre, even after attempting to adjust for case-mix, further indicating there has been a move towards manipulating more fractures in the emergency department.

Summary of management of fractures


  • For upper limb fractures there has been a slight reduction in the number given a follow up appointment. For all fracture types there there has been a significant increase in the proportion of follow-up appointments conducted virtually since the pandemic.
  • Those presenting at night and at weekends were more likely to have follow up appointments and have their fracture manipulated in theatre. While it may be that those with more obvious/complex fractures that require manipulation/follow-up are more likely to present at these times, rather than perhaps waiting until the next day, it may also be the result of less senior staff available at these times.
  • There has been a decrease post-pandemic in the number of outpatient procedures involving casts/splints/bandages and a decrease in diagnostic imaging in outpatients.
  • Over the last 5 years the proportion of fractures manipulated in theatre has decreased and the proportion manipulated in the emergency department has increased.
  • Those attending urgent treatment centres are more likely to have their fractures manipulated in theatre as this would generally not be possible at urgent treatment centres. Although the majority of fractures that require manipulation are seen in emergency departments.
  • The overall manipulation rate for forearm fractures has reduced over the last 5 years, which likely reflects a change in the culture, with displaced fractures now less likely to be manipulated. Indeed, the CRAFFT study is currently looking at whether there is a difference in outcomes between surgical reduction versus non-surgical casting for displaced distal radius fractures in children1.
  • Overall, there is a trend towards more conservative management of paediatric fractures.
  1. www.CRAFFTstudy.org

Opportunities to reduce hospital activity


We aimed to determine the scale of the potential opportunities to reduce hospital activity and costs if more conservative management of paediatric fractures is adopted.

It is not possible from the data to determine the most appropriate treatment at an individual patient level and exactly which activity could be reduced.

Some trusts are known to have adopted more conservative approaches to fracture management. Therefore, we have compared activity rates across trusts and calculated activity savings if all trusts reduced their levels of activity down to the level of the best performing trusts that may already be using more conservative management approaches.

Potential activity reductions considered:

  • reducing the percentage of emergency care attendances for toe and clavicle fractures where an x-ray is performed.

  • reducing the percentage of fractures where a follow-up outpatient appointment is given.

  • reducing the percentage of forearm and elbow fractures where a manipulation is performed in theatre.

For x-rays and outpatient attendances we have considered a reduction in activity down to the level of the lowest decile of trusts. However, for manipulations in theatre we have used the lowest quartile as there has already been a significant reduction in these over past 5 years and rates of manipulations in theatre are already low at many trusts.

Calculating proportions by trust


Includes only NHS trusts with 120+ attendances for fractures in 2022/23; this resulted in 8 trusts being excluded. Some trusts may have low numbers due to alternative provisions locally e.g. Royal Liverpool had small numbers which is unsurprising given its proximity to a specialist paediatric centre at Alder Hey. Independent providers were also excluded, the majority of these had small numbers of attendances for fractures (<120 per year).


Overall numbers and percentages for 2022/2023

No. of fractures

X-ray in ED

Follow-up

Follow-up without procedure

Follow-up with procedure

Manipulated in theatre

Manipulated in ED

Manipulated in ED & theatre

Clavicle

15,119

13,149 (87%)

9,171 (60.7%)

8,388 (55.5%)

783 (5.2%)

8 (0.1%)

10 (0.1%)

0 (0%)

Elbow

21,840

19,193 (87.9%)

17,704 (81.1%)

13,658 (62.5%)

4,046 (18.5%)

258 (1.2%)

177 (0.8%)

12 (0.1%)

Forearm

71,844

62,679 (87.2%)

46,217 (64.3%)

35,550 (49.5%)

10,667 (14.8%)

3,024 (4.2%)

2,686 (3.7%)

222 (0.3%)

Tibia/Fibula

13,740

11,709 (85.2%)

10,896 (79.3%)

8,153 (59.3%)

2,743 (20%)

317 (2.3%)

140 (1%)

26 (0.2%)

Toe

14,604

11,117 (76.1%)

6,406 (43.9%)

5,830 (39.9%)

576 (3.9%)

9 (0.1%)

177 (1.2%)

1 (0%)

When considering potential savings in terms of follow-up appointments, we have considered all follow-up appointments (with and without procedures).

X-rays for Clavicle and Toes fractures by trust

Evidence suggests that x-raying clavicle and toe fractures in the emergency department is often unnecessary, as it doesn’t add further useful information to a clinician’s assessment or alter management.

Percentage of clavicle fractures x-rayed

Min

5.9 %

1st quartile

87.7 %

Median

93.2 %

3rd quartile

95.7 %

Max

100 %

There would be an annual reduction in England of 1,986 (15.5%) x-rays in emergency care if all trusts reduced the percentage of x-rays to the level of the lowest decile of trusts (77.3%).

Percentage of toe fractures x-rayed

Min

2.4 %

1st quartile

72.6 %

Median

82.4 %

3rd quartile

89.7 %

Max

100 %

there would be an annual reduction in England of 2,412 (22.5%) x-rays in emergency care if all trusts reduced the percentage of x-rays to the level of the lowest decile of trusts (62.3%).

Cost of x-raying clavicle and toe fractures

Clavicle fracture

Toe fractures

All attendances at urgent treatment centres are costed at £85 regardless on whether a fracture is x-rayed.

For both clavicle and toe fractures without an x-ray the median cost of an emergency department attendance is £126 compared to a median cost of £184 when the fracture is x-rayed, suggesting a saving in the region of £58 for each clavicle or toe fracture not x-rayed in the emergency department.

Upper limb fractures with follow-up by trust (2022/23)


Min

19.8 %

1st quartile

56.2 %

Median

65.1 %

3rd quartile

77.2 %

Max

98 %

There would be an annual reduction in England of 13,768 (30.7%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (46%).

Min

25.9 %

1st quartile

74.2 %

Median

83.6 %

3rd quartile

90.4 %

Max

100 %

There would be an annual reduction in England of 4,486 (25.8%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (61.8%).

Min

5.6 %

1st quartile

46.5 %

Median

61.2 %

3rd quartile

82.2 %

Max

97.4 %

There would be an annual reduction in England of 4,440 (49.9%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (31.4%).

Lower limb fractures with follow-up by trust (2022/23)


Min

20.2 %

1st quartile

72.8 %

Median

83.7 %

3rd quartile

90.1 %

Max

100 %

There would be an annual reduction in England of 2,817 (26.4%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (60%).

Min

11.1 %

1st quartile

31.7 %

Median

45.4 %

3rd quartile

56.9 %

Max

100 %

There would be an annual reduction in England of 3,260 (53%) follow-up appointments if all trusts reduced the percentage of follow-ups to the level of the lowest decile of trusts (21.3%).




Combining the potential reduction in the number of follow-up appointments for all of the fracture types included in this study, there could be a total annual reduction of 28,771 (33%) follow-up appointments in England.

This may be an underestimation as some children may have more than one follow-up appointment that could be deemed unnecessary.

Number of clavicle fracture follow-ups by trust (2022/2023)



This includes all outpatient attendances, including physiotherapy appointments, in the 3 months post-fracture.

There is significant variability between trusts in the number of follow-up appointments for clavicle fractures.

Many clavicle fractures should not require follow-up yet some trusts are averaging 2-3 follow-up appointments per clavicle fracture, indicating a potential to further decrease follow-up appointments if second and subsequent appointments are considered.

Cost of face-to-face follow-up appointments

For all fracture types the median cost of the first face-to-face outpatient attendance is £175. Prices are not available for virtual follow-up appointments, although the costs will be reduced compared to face-to-face appointments.

Differences between our approach and the GIRFT metric


There are some significant differences between the data included by GIRFT/Model Hospital and the data used in this study. GIRFT/Model Hospital:

  • include all forearm and wrist fractures, whereas we excluded certain fracture types, e.g open fractures which are assumed to all require treatment in theatre.

  • include re-manipulations in theatre, whilst we have excluded those coded as re-manipulations.

  • use a 3-year average, whilst we used only the most recent year where follow-up data is available (2022/23).

  • use the number of fractures manipulated in theatres taken directly from inpatient data and total A&E attendances for those aged 16 and under as the denominator. We have linked emergency care data to inpatient data and so are only considering manipulations in theatre for patients identified in the emergency care dataset as having a fracture.

The way the GIRFT metric is calculated means that it does not account for any regional differences in fractures rates, but it is unaffected by the poor recording of diagnoses codes in emergency care. Our measure accounts for regional differences, but does rely on the assumption that the fracture types requiring interventions and fractures that do not are equally likely have a diagnosis code recorded in emergency care, which may not always be the case.

Comparing methods for calculating the rate of manipulations

Graphs show our data for the number of forearm fractures manipulated in theatre in 2022/2023 (identified by linking to emergency care fracture records), but use different denominators to calculate the rate.

Top figure shows the 20 trusts with the highest (red) and 20 trusts with the lowest (green) rates of manipulations in theatre using total A&E attendances as the denominator.

Bottom figure uses the number of A&E attendances for forearm fractures as the denominator, and the same trusts labelled above are shown in their new positions according to this new metric. We have used this method to calculate manipulation rates in the subsequent slides, as it accounts for differences between trusts in the proportion of emergency department attendances that are for fractures. However, as diagnoses codes are not always recorded using this method we do have to make the assumption that the fractures that are recorded are representative to true case-mix.

Example 1, using total A&E attendances as the denominator The Royal Cornwall Hospitals Trust has a rate of ~16.6 forearm manipulations in theatre/10,000 A&E attendances, which puts it as the 11th highest rate in England. Using the number of forearm fractures as the denominator the manipulation rate of forearm fractures in theatre is 5.9%, moving The Royal Cornwall Hospitals Trust out of the highest quartile down to 43rd highest.

Example 2, Chelsea and Westminster Hospital NHS Foundation trust has a rate of 1.3 forearm manipulations in theatre/10,000 A&E attendances, which is the 16th lowest rate in England. However, when the number of forearm fractures is used as the denominator the rate of forearm manipulations in theatre is 6%, suggesting the trust doesn’t actually perform as well as first thought, moving it to the 42nd highest, with a similar rate to The Royal Cornwall Hospitals Trust.

Forearm fractures manipulated in theatre by trust (2022/23)


Min

0.2 %

1st quartile

2.3 %

Median

4.4 %

3rd quartile

6.5 %

Max

21.4 %


There could be an annual reduction in England of 1,747 (54.5 %) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (2.3%).

Elbow fractures manipulated in theatre by trust (2022/23)

NOTE: Very low numbers at many providers

Min

0 %

1st quartile

0.5 %

Median

1.3 %

3rd quartile

2 %

Max

8.8 %


There could be an annual reduction in England of 177 (67%) manipulations in theatre, if all trusts reduced their percentage to the level of the lowest quartile (0.5%). This size of reduction is unlikely to have a significant impact in freeing up theatre time.

Cost of manipulations in the emergency department vs theatre

Forearm fractures

Elbow fractures


Those not manipulated in the emergency department are those that are manipulated but in theatre.

Median cost of ED attendance with manipulation (£)

Median cost of ED attendance without manipulation (£)

Calculated cost of manipulation in ED (£)

Median cost of manipulation in theatre (£)

Potential saving per manipulation in ED (£)

Forearm

288

184

104

1,951

1,847

Elbow

288

184

104

2,231

2,127

In addition to the cost savings, manipulating more fractures in the emergency department would free up theatre time.

Sites from CRAFFT study (2023/24)

Manipulations of forearm fractures in theatre



  1. www.CRAFFTstudy.org


Trusts with hospitals participating in the CRAFFT study1 are shown in black; it can be seen that they are fairly evenly spread relative to other hospital sites, and aren’t clustered towards the lower end.

It should be noted that this chart is showing data from the most recent year, 2023-24, rather than 2022/23 which was used for the previous analysis.

Summary of the potential activity reductions


  • There is scope for a 19% reduction in the number of x-rays for clavicle and toe fractures in emergency care in England, equivalent to at least 4,400 x-rays per year.

  • The number of follow-up appointments for forearm, elbow, clavicle, tibia/fibula and toe fractures could be reduced by 33%, equivalent to at least 28,800 follow-ups per year in England. This is based on reducing the number of first follow-ups, but it appears a number of children have more than one unnecessary follow-up so this is likely an underestimate of the potential savings.

  • The number of forearm and elbow fractures manipulated in theatre could be reduced by an additional 55%, equivalent to a reduction of 1,900 manipulations in theatre in England per year. Assuming manipulation of a forearm/elbow fracture takes on average 45 mins1,2, this equates to 8.5 weeks of theatre time per year.

  • While some trusts have already implemented more conservative management approaches, particularly for manipulations, there appear to be some trusts that could still significantly benefit from adopting this approach. At many trusts there is significant scope to reduce number of x-rays performed for fractured clavicles and toes and the number of follow-up appointments for all fracture types.

Clavicle

Elbow

Forearm

Tibia/Fibula

Toe

Total

Reduction in x-rays in emergency care

1,986 (15.5%)

-

-

-

2,412 (22.5%)

4,398 (18.7%)

Reduction in follow-up appts

4,440 (49.9%)

4,486 (25.8%)

13,768 (30.7%)

2,817 (26.4%)

3,260 (53%)

28,771 (32.7%)

Reduction in manipulations in theatre

-

177 (67%)

1,747 (54.5%)

-

-

1,924 (55.4%)

  1. Betham C et al. (2011) Manipulation of simple paediatric forearm fractures: a time-based comparison of emergency department sedation with theatre-based anaesthesia. N Z Med J. 124(1344):46-53.
  2. Seefried S et al (2022) Paediatric forearm fractures manipulated in the emergency department: incidence and risk factors for re-manipulation under general anaesthesia. N Z Med J. 135(1560):60-66.

Discussion

In agreement with previous studies we find forearm fractures are the most common followed by elbow fractures, and also higher fractures incidences in the summer and older boys due to higher levels of physical activity1,2. We find geographical variation in the recorded incidences of fractures in emergency care, some of this is likely the result of poor recording of fractures in emergency care in some areas. However, a previous paper found significant geographical variation with lower rates in London, similar to our results1. It is thought that regional variation may be due to levels of physical activity, obesity levels and the ethnic make up of the area; fracture rates were found to be higher in white children compared to those of black or South Asian ethnicity and to correlate with obesity and levels of physical activity1.

In the Paediatric Trauma and Orthopaedic Surgery GIRFT report it was suggested that there was scope to reduce the number of paediatric forearm manipulations in theatre by 80%3. That study used data from 2016-2019, in our study we have found since 2019/2020 the proportion of forearm fractures manipulated in theatre has fallen by 54%, from just over 8% in 2019/20 to under 4% in 2023/24.

It appears that there is the possibility to further reduce manipulations in theatre, particularly at some trusts, although overall at a national level the decrease in manipulation in theatre is likely to start slowing as the numbers get smaller. The switch to manipulating more fractures in the emergency department rather than in theatre will not only would save the NHS money, operating theatre time and resources, but will improve care for children and their families as treatment is quicker and less disruptive.

As highlighted within the Paediatric Trauma and Orthopaedic Surgery GIRFT report there are a number of factors that may be reduce the proportion of manipulations in the emergency department, including concerns about breach times, a lack of space/facilities to perform sedation, and a lack of familiarity with techniques3. Concerns around litigation may also lead to less conservative management, especially with elbow fractures which can lead to rare, but severe, complications. It is possible factors related to culture, lack of experience and litigation may also influence conservative management when it comes to reducing x-rays for clavicle and toe fractures and reducing follow-up appointments.

Nottingham University Hospitals NHS Trust, who are known to utilise more conservative management of paediatric fractures including routinely manipulating forearm fractures in the emergency department3,4, have, as expected, one of the lowest proportions of forearm fractures manipulated in theatre. In 2022/2023 only 0.5% of forearm fractures were manipulated in theatre (while 11.81% were manipulated in the emergency department) meaning only 4% of all forearm fractures requiring manipulation were performed in theatre. In terms of follow-up appointments 57% of forearm fractures receive a follow-up appointment, which is just above the lowest quartile.

  1. Moon RJ et al (2016) Ethnic and geographic variations in the epidemiology of childhood fractures in the United Kingdom. Bone. 85:9-14
  2. Mamoowala N et al (2019) Trends in paediatric distal radius fractures: an eight-year review from a large UK trauma unit. Ann R Coll Surg Engl. 101(4):297-303
  3. Paediatric Trauma and Orthopaedic Surgery. GIRFT Programme National Specialty Report. April 2022. https://gettingitrightfirsttime.co.uk/girft-reports/
  4. Bryson D et al. (2016) The lost art of conservative management of paediatric fractures. Bone Joint 360. 5(1):2-8.

Discussion (continued)

While at a national level the scope for significant further reductions in manipulations in theatre is likely to become limited, there is perhaps more scope in the future to reduce activity in terms of reducing unnecessary x-rays in the emergency department for clavicle and toe fractures, and in reducing the number of follow-up appointments.

The total number of forearm fractures that are manipulated has been decreasing, and there is perhaps scope for this to decrease further. Indeed, the CRAFFT study being conducted at over 45 sites in England is investigating whether there are any differences in outcomes between surgical reduction versus non-surgical casting for displaced distal radius fractures in children1.

The GIRFT report found some trusts have moved towards splinting fractures in the emergency department with a virtual follow-up, rather than a temporary cast and then referral to a fracture clinic1. From our data the use of virtual follow-ups appears widespread, but there may be scope to reduce virtual appointments, especially as some trusts with high overall follow-up rates have a particularly high number of virtual appointments.

Evidence suggests that many x-rays of clavicle fractures are unnecessary as they tend to not add significantly to a clinician’s assessment or alter management2. However, almost all trusts still are x-raying the vast majority of potential clavicle fractures so the proportion of x-rays is still high even for the lowest decile of trusts (77%). Therefore our numbers are likely to be an underestimate of what activity savings could be potentially achieved. The same is likely true for toe fractures. It has been found that while most more experienced clinicians were comfortable treating clavicle fractures without x-rays, more junior clinicians were not2.

Our absolute number estimates of reductions in activity may be an underestimate, because diagnoses are not reliably being recorded by some trusts in the emergency department. It is also possible that there may be some bias on the types of fractures attending emergency care that are given a diagnosis code. For example, it is possible at trusts that do not consistently record diagnosis codes in emergency care may be more likely to record fractures requiring manipulation than those that do not require manipulation or follow-up. However, when looking at trusts there was no significant relationship between the proportion of emergency care attendances without diagnosis codes and the proportion of fractures manipulated in theatre.

This report does highlight the need for more accurate and consistent recording of diagnoses in emergency care.


  1. https://crafft-study.digitrial.com/
  2. Lirette MP et al. (2018) Can paediatric emergency clinicians identify and manage clavicle fractures without radiographs in the emergency department? A prospective study. BMJ Paediatr Open. 10;2(1):e000304

Limitations


We are relying on the coding/reporting of fractures, manipulations, x-rays and outpatient appointments within the the SUS datasets. Some of the variability in the number of fractures, x-rays, physiotherapy referrals, follow-up appointments and manipulations between trusts and over time could be due to issues with the coding.

As diagnosis code is not always recorded in the emergency care dataset our incidence rates give the incidence of fractures recorded in emergency care, and only include closed fractures, open fractures were excluded.

The coding of fractures is not specific enough to determine at an individual level which fractures could be managed more conservatively, so we are relying on comparing proportion between trusts, but but we can’t be sure whether all trusts have a similar proportion of more complex fractures that do require manipulation and follow-up.

There will be a small number of cases where a child has more than one fracture or other injuries recorded in emergency care (<1%), so it is possible any follow-up appointments or manipulations could potentially be for a different injury/fracture sustained at the same time.

Data is allocated to the trust where the child attended the emergency department, e.g. if a child first attended the emergency department at trust A while on holiday but subsequently received follow-up appointments at trust B the fracture and subsequent follow-up would be included in the data for trust A.

The number of elbow manipulations recorded in theatre appears lower than would be expected, which may be due to coding issues. The lack of detailed coding of fractures makes it difficult to determine what is an elbow fracture and may mean that some are classified as forearm fractures, e.g. the SNOMED code for ‘Closed fracture of radius (disorder)’ is the most commonly used, and while we have classified these as forearm fractures, fractures of the proximal radius would be considered an elbow fracture. This may in part explain why we see a smaller number of elbow manipulations in theatre than would be expected, as they are included within forearm fractures. Also, HRG groupings for manipulations in theatre do not distinguish between forearm and elbow procedures, so it is not possible to determine from these which are forearm and which are elbow manipulations. We have only considered elbow manipulations in theatre that could be conducted in the emergency department, i.e. those without internal fixation such as wires or pins. Therefore our elbow manipulation number might also be affect by the propensity of individual trusts to use internal fixation for elbow fractures. We have also not included re-manipulations in our data.

These potential reductions in activity are for England only, but there is likely also the potential for activity savings in the other countries of the UK.

Cost savings are calculated from HRG prices and are only indicative estimates of potential cost savings.

Future work


To fully understand the potential cost savings of these reductions in activity a full health economic analysis would be required.

It may be helpful to do some more detailed mapping and analysis of patient pathways to better understand how fractures are being managed, and where further activities savings could be made with more conservative management.

There are currently trends towards more conservative management, particularly regarding increasing manipulations in the emergency department, so there is scope to investigate the extent to which these trends could continue and further activity can be reduced.

Future work could also focus on understanding the degree in variation between trusts in the proportion of forearm and elbow fractures that are manipulated in theatre with the use of internal fixation, and whether there are fractures that could be manipulated without the need for internal fixation.

Appendix A- Forearm and Clavicle fracture SNOMED codes

Forearm

208388003

Fracture at wrist and/or hand level (disorder)

209264008

Closed fracture dislocation of wrist (disorder)

209265009

Closed fracture dislocation distal radioulnar joint (disorder)

209284007

Closed fracture subluxation of distal radioulnar joint (disorder)

67730008

Closed Bennett's fracture (disorder)

307713000

Closed Barton's fracture (disorder)

208324004

Closed dorsal Barton's fracture (disorder)

208323005

Closed volar Barton's fracture (disorder)

209283001

Closed fracture subluxation of the wrist (disorder)

263102004

Fracture subluxation of wrist (disorder)

61653009

Bennett's fracture (disorder)

263103009

Fracture subluxation of distal radioulnar joint (disorder)

1290784005

Stress fracture of bone of wrist region (disorder)

1303397005

Fracture of bone of wrist region (disorder)

1285722006

Fracture of distal end of left ulna (disorder)

14430001000004100

Fracture of distal end of right ulna (disorder)

27094009

Skillern's fracture (disorder)

281530009

Fracture of ulnar styloid (disorder)

41036008

Closed fracture of styloid process of ulna (disorder)

263208005

Fracture of distal end of radius and ulna (disorder)

33192001

Closed fracture of lower end of radius AND ulna (disorder)

50397009

Closed fracture of distal end of ulna (disorder)

208318005

Closed fracture of ulna, lower epiphysis (disorder)

6163002

Closed fracture of head of ulna (disorder)

263199001

Fracture of distal end of radius (disorder)

58722007

Moore's fracture (disorder)

448355005

Greenstick fracture of distal radius (disorder)

737262009

Fracture of lower end of radius with volar tilt (disorder)

737261002

Fracture of lower end of radius with dorsal tilt (disorder)

123972004

Reversed Colles' fracture (disorder)

123618009

Closed reverse Colles' fracture (disorder)

281527002

Fracture of radial styloid (disorder)

208325003

Closed fracture radial styloid (disorder)

426467005

Hutchinson's fracture (disorder)

18310001000004100

Fracture of distal end of right radius (disorder)

16542901000119100

Closed fracture of metaphysis of distal end of right radius (disorder)

1285724007

Fracture of distal end of left radius (disorder)

16542861000119100

Closed fracture of metaphysis of distal end of left radius (disorder)

123971006

Colles' fracture (disorder)

269083002

Closed Colles' fracture (disorder)

17222009

Closed fracture of distal end of radius (disorder)

448838000

Closed extraarticular fracture of distal radius (disorder)

208326002

Closed fracture distal radius, intra-articular, die-punch (disorder)

704212006

Closed fracture of distal epiphysis of radius (disorder)

1279881008

Closed fracture of metaphysis of distal end of radius (disorder)

35442005

Closed fracture of lower end of forearm (disorder)


307172007

Fracture dislocation distal radioulnar joint (disorder)

1264544004

Fracture of bone adjacent to prosthesis of wrist joint (disorder)

12217801000119100

Fracture of bone adjacent to prosthesis of left wrist joint (disorder)

12202711000119100

Fracture of bone adjacent to prosthesis of right wrist joint (disorder)

1303394003

Fracture of bone of left wrist region (disorder)

1303396001

Fracture of bone of bilateral wrist regions (disorder)

1303395002

Fracture of bone of right wrist region (disorder)

46773004

Quervain's fracture (disorder)

3228009

Closed fracture of shaft of radius (disorder)

12676007

Fracture of radius (disorder)

28078000

Closed fracture of shaft of bone of forearm (disorder)

53627009

Closed fracture of radius AND ulna (disorder)

53792000

Closed fracture of shaft of ulna (disorder)

54556006

Fracture of ulna (disorder)

54645004

Barton's fracture (disorder)

54819005

Closed fracture of shaft of radius and ulna (disorder)

65966004

Fracture of forearm (disorder)

71555008

Closed fracture of ulna (disorder)

75857000

Fracture of radius AND ulna (disorder)

91419009

Closed fracture of forearm (disorder)

111640008

Closed fracture of radius (disorder)

208309008

Closed fracture radius and ulna, middle (disorder)

208322000

Closed Galeazzi fracture (disorder)

208513000

Multiple fractures of forearm (disorder)

263198009

Fracture of shaft of radius (disorder)

263200003

Volar Barton's fracture (disorder)

263201004

Dorsal Barton's fracture (disorder)

263204007

Fracture of shaft of ulna (disorder)

263205008

Fracture of distal end of ulna (disorder)

263207000

Fracture of shaft of radius and/or ulna (disorder)

268824003

Fracture of radius and/or ulna due to birth trauma (disorder)

271576001

Galeazzi fracture dislocation (disorder)

281528007

Fracture of olecranon (disorder)

281529004

Fracture of coronoid process of ulna (disorder)

287074009

Fracture malunion - forearm (disorder)

390986009

Torus fracture of radius (disorder)

429655000

Closed torus fracture of radius (disorder)

704056001

Stress fracture of ulna (disorder)

704059008

Stress fracture of radius (disorder)

733235002

Fracture of shaft of ulna and radius (disorder)

1285721004

Fracture of right ulna (disorder)

1303390007

Fracture of bone of left forearm (disorder)

1303391006

Fracture of bone of right forearm (disorder)

446461000124103

Fracture of right radius (disorder)

12960001000004100

Fracture of left radius (disorder)

13270001000004100

Fracture of left ulna (disorder)

Clavicle

58150001

Fracture of clavicle

33173003

Closed fracture of clavicle

1658003

Closed fracture of acromial end of clavicle

87376003

Closed fracture of shaft of clavicle

48561006

Closed fracture of sternal end of clavicle

88196000

Fracture of interligamentous part of clavicle (disorder)

1303380004

Fracture of left clavicle (disorder)

1303379002

Fracture of bone of bilateral clavicles (disorder)

1303381000

Fracture of right clavicle (disorder)

41972004

Fracture of shaft of clavicle (disorder)

56642004

Fracture of sternal end of clavicle (disorder) 

733403004

Multiple fractures of clavicle (disorder)

208510002

Multiple fractures of clavicle, scapula and humerus (disorder)

431011000

Nonunion of fracture of clavicle (disorder)

704069002

Stress fracture of clavicle (disorder) 

Appendix B- Elbow fracture SNOMED codes

Elbow

123973009

Monteggia's fracture (disorder)

1303382007

Fracture of left olecranon (disorder)

1303383002

Fracture of right olecranon (disorder)

1303392004

Fracture of bone of left elbow joint region (disorder)

1303393009

Fracture of bone of right elbow joint region (disorder)

16866431000119100

Closed fracture of capitellum of right humerus (disorder)

16867081000119100

Closed fracture of capitellum of left humerus (disorder)

19259001

Closed fracture of upper end of radius AND ulna (disorder)

208267005

Closed fracture distal humerus, lateral condyle (disorder)

208270009

Closed fracture of distal humerus, trochlea (disorder)

208271008

Closed fracture distal humerus, lateral epicondyle (disorder)

208272001

Closed fracture distal humerus, capitellum (disorder)

208273006

Closed fracture distal humerus, bicondylar (T-Y fracture) (disorder)

208274000

Multiple closed fractures of distal humerus (disorder)

208294009

Closed fracture olecranon, extra-articular (disorder)

208295005

Closed fracture of proximal ulna, comminuted (disorder)

208296006

Closed fracture proximal radius, comminuted (disorder)

208298007

Closed fracture olecranon, intra-articular (disorder)

209252000

Closed fracture dislocation elbow joint (disorder)

209253005

Closed fracture dislocation superior radioulnar joint (disorder)

209258001

Closed fracture subluxation of elbow joint (disorder)

209259009

Closed fracture subluxation superior radioulnar joint (disorder)

21419000

Closed fracture of medial condyle of humerus (disorder)

2295008

Closed fracture of upper end of forearm (disorder)

263078002

Fracture dislocation of elbow joint (disorder)

263100007

Fracture subluxation of elbow joint (disorder)

263101006

Fracture subluxation of superior radioulnar joint (disorder)

263192005

Fracture of distal end of humerus (disorder)

263193000

Supracondylar fracture of humerus (disorder)

263195007

Fracture of proximal end of radius (disorder)


263196008

Fracture of radial head (disorder)

263197004

Fracture of radial neck (disorder)

263203001

Fracture of proximal end of ulna (disorder)

263206009

Fracture of proximal end of radius and ulna (disorder)

269080004

Closed fracture of the distal humerus (disorder)

281525005

Fracture of the lateral humeral epicondyle (disorder)

281526006

Fracture of the medial humeral epicondyle (disorder)

29045004

Closed Monteggia's fracture (disorder)

302222008

Elbow fracture - closed (disorder)

309464009

Elbow fracture (disorder) 

33041006

Closed fracture of proximal end of ulna (disorder)

440366004

Closed fracture of the medial epicondyle of humerus (disorder)

441496000

Transcondylar fracture of distal humerus (disorder)

442448003

Fracture of head of radius with dislocation of distal radioulnar joint and interosseous membrane disruption (disorder)

58580000

Closed supracondylar fracture of humerus (disorder)

5895007

Closed multiple fractures of upper end of radius (disorder)

64902007

Closed fracture of olecranon process of ulna (disorder)

68819003

Closed fracture of coronoid process of ulna (disorder)

68854005

Closed fracture of head of radius (disorder)

700147004

Avulsion fracture of medial epicondyle of humerus (disorder)

704208000

Closed fracture of proximal epiphysis of radius (disorder)

704410001

Closed transcondylar fracture of distal humerus (disorder)

705076001

Closed fracture of epiphyseal plate of distal humerus (disorder)

71139009

Closed fracture of proximal end of radius (disorder)

72497001

Closed fracture of neck of radius (disorder)

733408008

Fracture of lateral condyle of humerus (disorder)

733409000

Fracture of medial condyle of humerus (disorder)

7341005

Closed multiple fractures of upper end of ulna (disorder)

80767005

Closed fracture of condyle of humerus (disorder)

Appendix C- Tibia/Fibula and Toe fracture SNOMED codes

Tibia/Fibula

31978002

Fracture of tibia (disorder)

6698000

Closed trimalleolar fracture (disorder)

6990005

Fracture of shaft of tibia (disorder)

15385006

Closed fracture of medial malleolus (disorder)

20433007

Fracture of upper end of tibia (disorder)

23900009

Closed fracture of upper end of tibia (disorder)

25899002

Closed bimalleolar fracture (disorder)

28012007

Closed fracture of shaft of tibia (disorder)

47848000

Closed fracture of condyle of tibia (disorder)

71830006

Supination-adduction injury of ankle, stage 2 (disorder)

87905008

Gosselin's fracture (disorder)

123975002

Trimalleolar fracture (disorder)

208610006

Closed fracture proximal tibia, medial condyle (plateau) (disorder)

208611005

Closed fracture proximal tibia, lateral condyle (plateau) (disorder)

208612003

Closed fracture proximal tibia, bicondylar (disorder)

208613008

Closed fracture intercondylar spine of tibia (disorder)

208629000

Closed fracture of tibia and fibula, shaft (disorder)

208634001

Closed fracture distal tibia (disorder)

208635000

Closed fracture distal tibia, extra-articular (disorder)

208636004

Closed fracture distal tibia, intra-articular (disorder)

208662008

Closed fracture ankle, bimalleolar, low fibular fracture (disorder)

208663003

Closed fracture ankle, bimalleolar, high fibular fracture (disorder)

208666006

Closed fracture ankle, trimalleolar, low fibular fracture (disorder)

208667002

Closed fracture ankle, trimalleolar, high fibular fracture (disorder)

263237009

Closed fracture of tibial tuberosity (disorder)

263240009

Pilon fracture (disorder)

263241008

Tillaux fracture (disorder)

263244000

Bimalleolar fracture of ankle (disorder)

271577005

Fracture of shaft of tibia and fibula (disorder)

278537006

Fracture of distal end of tibia (disorder)

281531008

Fracture of medial malleolus (disorder)

281532001

Fracture of posterior malleolus (disorder)

281843000

Fracture of tibial spine (disorder)

413877007

Closed fracture of tibia AND fibula (disorder)

414293001

Fracture of tibia AND fibula (disorder)

428256003

Fracture of condyle of tibia (disorder)

428257007

Fracture of tibial plateau (disorder)

428797006

Closed osteochondral fracture of proximal tibia (disorder)

428798001

Closed fracture of tibial plateau (disorder)

442205007

Stress fracture of tibia (disorder)

445410003

Closed fracture of distal tibia and distal fibula (disorder)

446298003

Closed pilon fracture (disorder)

447139008

Closed fracture of tibia (disorder)

703998005

Closed bicondylar fracture of tibial plateau (disorder)


705080006

Closed fracture of epiphyseal plate of distal tibia (disorder)

705092006

Closed fracture of epiphyseal plate of proximal tibia (disorder)

733295004

Avulsion of tibial tuberosity (disorder)

735669008

Fracture of metaphysis of proximal tibia (disorder)

735671008

Fracture of lateral condyle of tibia (disorder)

735672001

Fracture of medial condyle of tibia (disorder)

735846008

Avulsion of ligament with bony fragment of medial malleolus (disorder)

39541000087106

Fracture of medial condyle of left tibia (disorder)

39551000087109

Fracture of medial condyle of right tibia (disorder)

40031000087104

Fracture of left tibial plateau (disorder)

40041000087105

Fracture of right tibial plateau (disorder)

40051000087108

Fracture of lateral condyle of left tibia (disorder)

40061000087106

Fracture of lateral condyle of right tibia (disorder)

40071000087102

Fracture of left medial malleolus (disorder)

40081000087100

Fracture of right medial malleolus (disorder)

10924841000119100

Closed fracture of medial condyle of right tibia (disorder)

10924881000119100

Closed fracture of medial condyle of left tibia (disorder)

75591007

Fracture of fibula (disorder)

21867001

Fracture of upper end of fibula (disorder)

28359007

Closed fracture of head of fibula (disorder)

34268009

Closed fracture of lateral malleolus (disorder)

59639009

Closed fracture of upper end of fibula (disorder)

67394003

Fracture of shaft of fibula (disorder)

77803008

Closed fracture of shaft of fibula (disorder)

208615001

Closed fracture fibula, neck (disorder)

208657007

Closed fracture ankle, lateral malleolus, low (disorder)

208658002

Closed fracture ankle, lateral malleolus, high (disorder)

263242001

Fracture of distal end of fibula (disorder)

281533006

Fracture of head of fibula (disorder)

281534000

Fracture of neck of fibula (disorder)

281535004

Fracture of lateral malleolus (disorder)

308153009

Closed fracture of distal fibula (disorder)

315643003

Dupuytren's fracture dislocation ankle (disorder)

442538002

Stress fracture of fibula (disorder)

447395005

Closed fracture of fibula (disorder)

704209008

Closed fracture of epiphysis of proximal fibula (disorder)

705082003

Closed fracture of epiphyseal plate of distal fibula (disorder)

733296003

Avulsion of head of fibula (disorder)

735842005

Fracture of lateral malleolus below syndesmosis (disorder)

735844006

Avulsion of ligament with bony fragment of lateral malleolus (disorder)

735845007

Fracture of lateral malleolus at syndesmosis (disorder)

735847004

Fracture of distal fibula above syndesmosis (disorder)

736517000

Avulsion fracture of anterior fibula (disorder)

19350001000004100

Stress fracture of tibia and fibula (disorder)

Toe

21351003

Fracture of phalanx of foot (disorder) 

81576005

Closed fracture of phalanx of foot (disorder)

302036006

Closed fracture dislocation of interphalangeal joint of toe (disorder)

209361003

Closed fracture dislocation of interphalangeal joint of multiple toes (disorder)

209378007

Closed fracture subluxation of interphalangeal joint of multiple toes (disorder)

209359007

Closed fracture dislocation of interphalangeal joint of single toe (disorder)

208712008

Closed fracture distal phalanx, toe (disorder)

705067008

Closed fracture of distal phalanx of lesser toe (disorder)

208711001

Closed fracture middle phalanx, toe (disorder)

705068003

Closed fracture of epiphyseal plate of lesser toe (disorder)

208713003

Closed fracture of multiple phalanges of toe (disorder)

208710000

Closed fracture proximal phalanx, toe (disorder)

704057005

Stress fracture of phalanx of foot (disorder)

11314801000119100

Stress fracture of phalanx of left foot (disorder) 

11314761000119100

Stress fracture of phalanx of right foot (disorder)

263093003

Fracture dislocation of toe joint (disorder)

263117000

Fracture subluxation of interphalangeal joint of toe (disorder)

209375005

Closed fracture subluxation of interphalangeal joint of single toe (disorder)



Appendix D

Manipulations in emergency department were identified using A&E Treatment Code:

10- Reduction

Manipulations in theatre were identified by one of the following OPCS codes recorded during an inpatient episode in the 3 months post-emergency care attendance.

  • W262 Manipulation of fracture of bone NEC
  • W268 Other specified
  • W269 Unspecified
  • W663 Primary manipulative closed reduction of fracture dislocation of joint NEC
  • W252 Closed reduction of fracture of bone and fixation using functional bracing system

X-rays in the emergency department were identified using A&E Investigation Code:

01- X-ray

Physiotherapy appointments were identified by one of the following:

  • SNOMED referral code for physiotherapy in ECDS- 306170007 Referral to physiotherapy service (procedure)
  • Treatment Function Code for physiotherapy in the outpatient dataset in the 3 months post-emergency care attendance- 650 Physiotherapy Service

Outpatient follow up appointments were identified using the following codes in the outpatient dataset in the 3 months post-emergency care attendance

Treatment function code was one of:

  • 110 Trauma and Orthopaedic service
  • 111 Orthopaedic Service
  • 115 Trauma Surgery Service
  • 214 Paediatric Trauma and Orthopaedic Service

Or 420 Paediatrics provided that the outpatient referral source was either: 10- initiated following an emergency care attendance (including minor injuries, walk in centres and urgent treatment centres) OR 04- not initiated following a referral from an emergency care department (including minor injuries, walk in centres and urgent treatment centres)

It was also required that the emergency care attendance discharge information did NOT have the SNOMED code- 3780001 Routine patient disposition, no follow-up planned (procedure)